Med-Surg Week 10 PP

A nurse assesses a patient after a traumatic brain injury.

Which assessment finding is the highest priority?

Patient has unequal pupils and decreasing level of consciousness

The nurse calculates a patient's Glasgow Coma Scale.

Assessment:

• Opens eyes to pain

• Uses inappropriate words

• Withdraws from pain

What is the GCS?

9

A patient is in a persistent vegetative state.

Which finding should the nurse expect?

Sleep-wake cycles are present without cognitive function

Which finding best differentiates locked-in syndrome from coma?

Vertical eye movements remain intact

Which laboratory result is most important to review first in a patient with altered mental status?

Blood glucose

A nurse is caring for an unconscious patient.

Which intervention has the highest priority?

Maintain airway patency

Which patient demonstrates decorticate posturing?

Arms flexed toward chest with clenched fists

The nurse develops a care plan for an unconscious patient.

Which intervention best prevents contractures?

Passive ROM exercises

A nurse suspects increased ICP.

Which assessment finding requires immediate provider notification?

Restlessness progressing to decreased responsiveness

A nurse is assessing a patient with coma.

Which nursing diagnosis is the highest priority?

Ineffective airway clearance

A nurse is caring for a client who suddenly loses consciousness, becomes rigid, and then develops rhythmic jerking of all extremities. Which type of seizure is the client most likely experiencing?

Generalized tonic-clonic seizure

A patient tells the nurse, "Right before my seizures, I smell something burning."

How should the nurse interpret this finding?

Aura preceding a focal seizure

The nurse witnesses a patient having a tonic-clonic seizure.

Which nursing action is the priority?

Protect the patient from injury.

Which intervention should the nurse perform after a seizure ends?

Place the client in the side-lying position.

A nurse is documenting observations during a seizure.

Which assessment is most important to document?

Exact sequence of movements

A client has epilepsy and asks why antiseizure medications must be taken every day.

The nurse responds:

"They prevent future seizures but do not cure epilepsy."

Which laboratory value is commonly monitored in patients taking antiseizure medications?

Drug serum level

A nurse recognizes that status epilepticus is occurring when:

Seizures continue without recovery of consciousness.

A client arrives in the emergency department actively seizing.

Which provider prescription should the nurse anticipate administering first?

IV lorazepam (Ativan)

A nurse is caring for a patient with epilepsy.

Which interventions should be included in the plan of care?

- Pad side rails.

- Keep suction equipment available.

- Keep the bed in the lowest position.

- Administer oxygen if needed.

A client reports severe unilateral headache with tearing of the left eye and nasal congestion. Which type of headache does the nurse suspect?

Cluster headache

A client states, "Before my migraine starts, I see flashing lights."

The nurse recognizes this as:

Aura

The nurse is teaching a client with migraines about trigger avoidance.

Which client statement indicates correct understanding?

"I'll identify foods and situations that trigger my headaches."

Which medication is considered first-line abortive therapy for an acute migraine?

Triptans

A nurse cares for a client experiencing a migraine.

Which intervention is most appropriate?

Quiet, dark environment

A client suddenly develops right-sided weakness and difficulty speaking.

What is the nurse's priority action?

Activate the stroke protocol.

A nurse is caring for a client with suspected ischemic stroke.

Which diagnostic test should be performed first?

Non-contrast CT scan

A client arrives in the emergency department 90 minutes after stroke symptom onset.

Which intervention should the nurse anticipate?

Immediate IV thrombolytic therapy if eligible

Which client is most likely experiencing a left hemispheric stroke?

Aphasia

A nurse is caring for a client receiving IV alteplase (tPA) for an ischemic stroke.

Which findings require immediate intervention?

-. Sudden severe headache

-. Blood pressure 188/110 mm Hg

-. New onset vomiting

-. Decreased level of consciousness

A client arrives in the emergency department reporting a sudden, severe headache described as "the worst headache of my life." The client also has neck stiffness and vomiting.

Subarachnoid hemorrhage

The nurse is caring for a client with a hemorrhagic stroke. Which finding requires immediate notification of the provider?

Decreasing level of consciousness

A client with a subarachnoid hemorrhage is at risk for cerebral vasospasm.

When should the nurse be most alert for this complication?

7–10 days after hemorrhage

The nurse is caring for a patient with increased intracranial pressure (ICP).

Which intervention is appropriate?

Elevate the head of the bed 15–30 degrees.

A nurse is caring for a patient with increased ICP.

Which action should the nurse avoid?

Encouraging the patient to cough and deep breathe frequently

A nurse is caring for a patient with a brain injury.

Which assessment finding indicates worsening increased intracranial pressure?

New onset unequal pupils

A patient with increased ICP has a prescription for mannitol.

The nurse understands the purpose of this medication is to:

Treat infection

A nurse is caring for a client after hemorrhagic stroke.

Which nursing intervention is the priority?

Maintain cerebral perfusion.

A nurse is caring for a patient with increased ICP.

Which interventions should be included in the plan of care?

-. Elevate HOB 15–30 degrees

-. Maintain a calm environment

-. Monitor neurologic status

-. Prevent constipation and straining

The nurse receives report on four patients. Which patient should the nurse assess first?

Patient with hemorrhagic stroke who has a new decrease in level of consciousness